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Retention of Drugs Sale Licence Application
Application Details
Drug Licence Type *    
Form 20 Licence Number* Form 20 Issue Date Form 20 validity upto*
Form 21 Licence Number* Form 21 Issue Date Form 21 validity upto*
Form 20-A Licence Number* Form 20-A Issue Date Form 20-A validity upto*
Form 21-A Licence Number* Form 21-A Issue Date Form 21-A validity upto*
Form 20-B Licence Number* Form 20-B Issue Date Form 20-B validity upto*
Form 21-B Licence Number* Form 21-B Issue Date Form 21-B validity upto*
Form 20-F Licence Number* Form 20-F Issue Date Form 20-F validity upto*
Form 20-G Licence Number* Form 20-G Issue Date Form 20-G validity upto*
Constitution of Shop/Firm*  
Name of Shop/Firm* Status of Premises*
Shop No./Plot No. *
Shop/Firm Colony* Shop/Firm Locality/ Village *
District* Tehsil *
Pincode * Area of Premises*    (Sq. Fts)
0    (Sq. Meters)
Applicant Personal Details
Applicant First Name* Applicant Last Name *
Father's/Husband's First Name* Father's/Husband's Last Name*
Date of Birth Mobile Number*
Email ID
Business/Occupation of Applicant in past 3 years *

Local Address of Applicant

House No. * Colony
District* Area/ Village *
Tehsil * Pincode*
Are Local address and Permanent Address same?

Permanent Address of Applicant

House No. * Colony
District* Area/ Village *
Tehsil * Pincode*
Applicant Qualification
Qualification Passing Year Marks Obtained Total Marks University/Board
Competent Person Details (if registered Pharmacist and Competent person are different)
Sno Salutation Name Father's/Husband's Name Date of Birth Experience Qualification University/Board ID Card ID Card No.
1.
Registered Pharmacist(s) Details
Sno Salutation Name Father's/Husband's Name Address Date of Birth Registration No. Registration Date Registration
valid upto
Qualification ID Card ID Card No. whether applied for further Renewal? University
1.


Declaration
I   hereby declare that all the details furnished in the form are valid and correct, in case any detail found to be incorrect/ invalid, I will be responsible and the Licensing Authority has the right to reject this application. I understand that In case of rejection, fee would not be refunded under any circumstances.
 I  hereby undertake to comply with all the provisions of THE DRUGS AND COSMETICS ACT, 1940 AND RULES, 1945 as applicable to me.